The Annual Report of the Kailakuri Health Care Project (KHCP) for the year 2010
Aim: Sustainable Health Care for the Poor by the Poor
Contents: 1. Introduction. 2. 2010 Statistics at a Glance. 3. Gender Disparity. 4. Low Cost Health Care at a Glance. 5. Annual Account for 2010. 6. Donor List. 7. Financial Situation and Budget. 8. The State of the Project. 9. The Mother-Child Village Programme. 10. The TB Programme. 11. General Patient Care. 12. The Diabetes Programme. 13. Staff, Training and Health Education. 14. Conclusion.
(1) Introduction:
Poverty and its deprivations are dehumanizing and destructive of health. The numbers are enormous. Funds are always tight. Services must be basic and low cost and the people must do them. External assistance is necessary because the scientific knowledge, skills and funding required are not available in the poor community. They have to be built in and built up.
Gradual building up of health services appropriate to needs is necessary in all communities. Going slowly allows recognition of needs and adjustment to changes and the nurturing of decision making and involvement. It allows the spreading of health awareness and messages through the community and it allows the community to understand the services, protect and support them and identify them as its own. Health service means health problem action. The common problems of the poor are overwhelmingly the most important problems. So actions not directed to these cannot be priority actions and are often commercially, employment-creation or academically motivated.
The present KHCP is the product of a 28 year development starting from a little run down church dispensary. Such clinics and dispensaries are not usually very relevant to community needs. Besides in mixed religio-ethnic communities it is difficult to reach the needs of the wider poor from a project based on one group. Even so the Thanarbaid Clinic gradually became the Thanarbaid Health Care Project and the pressure for services so great that it outgrew its capacity and had to divide. The KHCP which is now part of a secular NGO continues the service development process but has been able to develop more slowly and adjust more appropriately. However it has still had to struggle to solve its problems, find its funding and maintain medical supervision.
To hope for even moderately complete financial self reliance is unrealistic in the case of health care for the poor. Whatever the reasons the basic problem is madistribution of resources and expertise. Kailakuri is a move to rectify this but it must keep itself appropriate, low cost and realistic. Bangladesh has a population of over 150 million. About half are so poor that they have difficulty accessing their basic needs. The economic advance of the upper strata raising the prices of basic commodities, their control of inadequate public health services and the overall commercialization of health activities in general make things worse for the poor. The Kailakuri model should be developed and copied to meet their needs.
(2) 2010 Statistics at a Glance:
1. The Village Mother-Child Health Programme (VHP):
2. No. of Persons Receiving Health Education: 22,000
3. Outpatient Visits:
4. Inpatient Admissions:
(USD 172,000, NZD 229,000)
The KHCP provides a model of low cost health care for the poor.
(3) Gender Disparity: In a heavily male dominated society it is striking that all the Kailakuri statistics apart from TB and insulin patients show a high female predominance (outpatient 64%, inpatients 58%, tablet diabetes patients 58%, insulin patients 50% and TB 34%)!
(4) Low-Cost Health Care at a Glance:
(1) Antenatal care in the home for one mother/12 months health nutrition care in the home for one child: BDT 690 (USD 9, NZD 13) (2) Six months multidrug treatment course for one TB patient (cost of KHCP): BDT 1,100 (USD 15, NZD 20) (3) One general outpatient visit (incl. medications): BDT 84 (USD1.2, NZD 1.5) (4) Cost of keeping one inpatient admitted for one day (incl. medication, food for patient and attendant etc.) BDT 260 (USD 3.6, NZD 4.8) (5) Cost of supervision and treatment of one diabetes patient for one year (cost to KHCP) BDT 3,000 (USD 41, NZD 55) (6) Staff pay for 89 staff for one year (including doctor): BDT 4,287,000 (USD 59,000, NZD 78,000) (7) Average pay, one staff member for one month: BDT 4,000 (USD 55, NZD 73) (8) Total project expenditure for one year: BDT 12,500,000 (USD 172,000, NZD 229,000) (9) Approximate cost per person touched (appr. 25,000): BDT 500 (USD 7, NZD 9) (10) Fixed expenditure (total salary bill) per person touched: BDT 170 (USD 2, NZD 3)
The provision of health care for the poor at extremely low cost is possible because actions are simple, investigations minimal, staff non-professional, salaries low, medical supervision committed and correctly orientated and there is close cooperation with other organizations for cost sharing.
(5) Annual Account for the Year 2010
Expenditure
General, Diabetes and TB Programmes
Notes: (1) Expenditure Breakdown According to Programme:
(2) Approx. Exchange Rates: USD 1=BDT 72.8, NZD 1=BDT 54.7, Euro 1=BDT 98.0, Brit Stg. 1=BDT 1,153 (Feb 2011) (3) Income, receipts and expenditures relate to the project not to the IIRD central office. (4) Differences from the official audit are due to i) different time period (audit 15th February to the 14th February), ii) different format, iii) inclusion of rotating fund, etc. (5) Total expenditure 15% more than 2009 correlates roughly with inflation rate.
(6) 2010 Donor, Supporter List:
I. Overseas Donors and Supporters.
1. The Morgan Family Foundation (New Zealand).
Our very special thanks go to Mr.Garath Morgan a prominent New Zealand philanthropist and economist whose threefold support increase has moved us from a position of struggling to keep going to a position where we can concentrate on national leadership development (particularly search for a national doctor) and the development of an incountry funding base; both essential for long term sustainability.
2. New Zealand donors giving via the NZ Link Group, the NZ Anglican Mission Board and the NZCMS (including some very large private donations). 3. American donors (including some very generous donations) via the Maryknoll Fathers and P.S.D.I. 4. The members of the NZ Link Group. 5. Asia Connection Incorporated (USA). 6. Probash Bongo (Belgium)and the ten students who raised funds and erected a delivery suite building at Kailakuri. 7. S. Patrick’s Catholic Church, Lincoln, NZ. 8. The Quail Roost Foundation, USA. 9. Howick Presbyterian Church, NZ. 10. A British private doctor. 11. S. Stephen’s Anglican Church, Whangaparoa, NZ. 12. Rotary Club of Newmarket, Auckland, NZ. 13. S. Patrick’s Catholic Church, Greymouth, NZ. 14. S. Luke’s Anglican Church, Havelock North, NZ. 15. An Italian private donor. 16. Other Churches in NZ. 17. NZCMS, AAW and CWS for friendship, support and prayer back-up. 18. The NZ Bangladeshi Association and especially Mr. Ataur Rahman for enabling essential contacts in NZ and Bangladesh. 19. Fr. Bob McCahill (BD), The Maryknoll Fathers and PSDI (USA).
National-International Highlight: Md. Risal Mahmud, a young Muslim in Dhaka, presented the project with a gift of BDT 80,000, equivalent to almost two years’ wages, raised by donations from friends who sponsored him in keeping the thirty day Muslim fast as poor people keep it.
II. In-Country Support:
1. The Institute of Integrated Rural Development (IIRD), our parent NGO provides government authorization and liaison, the project manager’s salary and other support. 2. BIRDEM Hospital (Diabetes Association of Bangladesh) gives support to our poor diabetics, channels government aid in the form of concession priced insulin and provides free insulin for young diabetes.
Over the years BIRDEM Hospital has probably given more support to our work than any other group.
3. The Government of Bangladesh gives authorization, support through BIRDEM and Damien Foundation and local support at sub-district level. 4. Damien Foundation provides free investigations and medicines for TB patients and brings the Kailakuri TB service into the National TB Programme. 5. The Bangladesh National Society for the Blind Eye Hospital in Mymensingh provides free or low cost eye surgery for cataract and other eye patients. 6. Notre Dame College, Dhaka, provides almost free accommodation for our diabetes patients. 7. The Pirgacha Mission, the Maryknoll Father and Sisters, the Taize Brothers and the Marist Brothers and Sisters give various kinds of help including important advice when needed. 8. Prominent Bangladeshi friends in Dhaka and Madhupur give important advice, encouragement and promotional assistance. 9. The Bangladesh media has given publicity to the project, important for development of an incountry funding base and finding a national doctor.
(7) Financial Situation and Budget:
I. Income, Expenditure and Balances for 2009-10, 2010-11 and 2011-12(projected):
II. Income Breakdown (%):
III. Source of Foreign Donations:
Notes: (1) Financial data shown relate to January to December financial years (contrast February to February years of official audit). (2) Incomes and balances relate to the project except for the 2011-12 projected income and closing balance which are global. (3) Forward projection estimates are very rough because of the uncertainties involved. (4) Almost all income comes from private donations. (5) The huge increase in New Zealand proportion of donations is due mainly to the three-fold increase given by the Morgan Family Foundation (and the loss of Fr. Douglas Venne). (6) This plus several other large donations look to give us a balance to carry into 2012. (7) The low contribution of patient fees indicates the need to raise fees in line with inflation.
(8) The State of the Project:
Essential health care for the poor being done by the poor themselves is ongoing. Very many people are helped, health awareness is disseminated through the community and the project is a stabilizing influence in the community. It has had media publicity so that it is now quite widely respected. However it still has a lot of problems. The efforts of daily health care delivery, administration, ensuring funding and securing sustainability compete with each other. Mutual understanding and support of staff, community and central office still need to be fostered and strengthened.
The project comprises five departments: home-based mother-child care, TB programme, general outpatients, inpatients department and diabetes programme, backed up by garden-grounds-cows-and-buildings and by finance and administration. Each is technically quite good but with significant problems of appropriacy, efficiency and optimum staff utilization. Village workers as well as providing good primary mother child care should also be the monitors of community nutrition and health problems in constant dialogue with the rest of the project to enable adjustment to immediate and changing needs.
The loss of the project’s two principal funding and donor communication coordinators, Mrs. Libby Laing and Fr. Doug Venne has diverted even more of the medical officer-in-charge’s time to these roles. This along with increasing age and decreasing work capacity takes an increasing toll on programme supervision, problem solving, staff training and patient care. The counterside has been senior paramedic advance in responsibility taking for patient care, staff training and programme leadership. This however has its limitations and the needs are obvious and pressing.
Dr. Mariko Inui (from JOCS, Japan) comes for three month periods. Having given special priority to study of language, community and project methods she is now increasingly filling the gaps and making her own special contributions. She is very committed and has become essential to the project. Pijon Nongmin the project manager also accepted a long period of orientation and is similarly committed. He is active in management and problem solving. Problems are being solved and efficiency is improving.
Medical leadership should not just be for medical consultation, staff training and ensuring funding but should constantly evaluate the project’s appropriacy and efficiency in relation to the needs of the poor and be constantly active in programme problem solving. This requires long term undiverted leadership from a person with understanding of community health and ready to immerse and understand the local community, the situation of the poor and their health needs. Such a medical doctor must be sought to replace the present medical officer-in-charge. In the face of inadequate medical supervision the roles of fund seeking, monitoring and correspondence should not be medical roles. (9) The Mother, Child Village Health Programme (VHP):
Just as primary health mother-child care provides the basic groundwork for community health, so the Kailakuri network of mother child workers in the villages must be developed to be the basic health intelligence and executive agency of the KHCP in the local community. Statistics for 2010
Number of Villages 17 (population about 13,800) Staff 17: village workers 11, supervisors 6 Under-4 yr Child Care: 1093 children (8% less than 2010) at years’ end. Weight survey at years’ end showed nutrition problems in 4% (failure to gain weight over three consecutive months, drop of 0.8 Kg not yet regained or below 3rd centile on weight chart). This very low figure shows the quality of care and teaching given. Immunizations: Staff continue to support the government’s E.P.I. programme. Antenatal Care: 357 mothers were given ANC (14% more than 2010. The government provides only one oral contraceptive brand. Alternatives have to be bought on the local market. The commercial sector engineered an artificial crisis in availability and hence price increase of other brands. Hence more pregnancies). Delivery Care: 37% of ANC mothers had staff assisted deliveries. 51 deliveries (16% more than 2010) were assisted by KHCP staff, 44 in their homes and 7 at the health centre. Family Planning: Staff continue to motivate for the government programme and 24 couples received oral contraceptives from the VHP. Religio-ethnic Breakdown:
The total cost of the VHP for 12 months was BDT 1000,000 (USD 14,000, NZD 18,000) about BDT 690 (USD 9 and NZD 13) per mother or child cared for. This is highly cost effective.
(10) The TB Programme :
This programme carried out by KHCP staff under Damien Foundation is a part of the government’s national TB programme and a sub-centre of the Madhupur TB clinic.
Kailakuri Results:
I. Success Rate:
43 sputum positive patients started treatment between July 2009 and June 2010. Eight were subsequently transferred to other centres. Of the remaining 35, 34 were cured, ie: 97% cure rate (spectacular result).
II. 2010 Statistics
Total number treated 86 (3% decrease) No. continuing from 2009 34
Completed – 55 Transferred – 3 Failed – 1 - 62 Defaulted – 1 Died – 2 Continuing into 2010 24 (Preventive treatment 3) III. Patient Analysis: Category 1 (new sputum positives) : 51 (60%) Category 2 (retreatment) : 8 (10%) Category 3 (non-pulmonary) : 27 (30%) 100% followed treatment regularly. Distance of home: 65% were from within five miles (25% within two miles). 39% were under 30 years’ age. (Male 66%, female 34%, Muslim 69%, Christian 25%, Hindu 6%) 31 patients (35%) were hospitalized, 25 at Kailakuri and 6 at Jalchatra. 6% of patients also had diabetes.
IV. Case Finding:
With excellent treatment results and decreasing patient numbers, the programme obviously needs to undertake active TB case finding.
The total cost to KHCP of the TB programme was BDT 100,000 (USD 1,500, NZD 1,800).
(11) General Patient Care :
General patient care and diabetes patient care each involve about a third of project expenditure and a quarter of project staff. These two primary health care programmes carried out by locally trained ordinary village people are the project’s most innovative interventions, probably the two most appreciated by the community and the two which attract the greatest outside interest.
2010 Statistics:
I. Outpatients: Total no. of patient visits: 20,296 (10% more than 2009) Muslim 85%, Christian 11%, Hindu 4% Male 36%, female 64%. Under 5 y. age children 6%. Distance of home: 0 – 2 miles 42%, 3 – 5 miles 46%, over 5 miles 12%. Top ten problems: pain, peptic ulcer, weakness, asthma, skin infection/sores, emotional /psychiatric problems, gynecological problems, urinary tract infection, epilepsy and hypertension.
Followed by: anaemia, worms, otitis media, bronchitis, diarrhoeal diseases, virus infections, allergies and arthritis/sciatica.
Note: The overwhelming preponderance of Muslim women almost all from within five miles and of patients with pains, weakness and emotional-psychiatric problems presents a picture of a dense rural Muslim population whose women folk probably suffer emotional problems due to social restriction.
The cost of running the general outpatient department for 12 months was approximately BDT 1,700,000 (USD 23,000, NZD 31,000) making cost per visit BDT 84 (USD 1.2, NZD 1.5) which includes salaries, medicines, stationary, etc. This is low cost health care.
II. Inpatients: Total no. of admissions (general plus diabetes) 986 (14% more than 2009). General patients 743 (21% increase), diabetes patients 243 (3% decrease).
The average number of admitted patients (general plus diabetes) was 34 and the average duration of stay for the general patients was 13 days. General Patients Muslim 65%, Christian 28%, Hindu 7%. Male 42% , female 58%, under five years 20% Top Ten Problems Pregnancy-delivery-newborns, malnutrition, followed far behind by: diarrhoeal diseases, then virus fevers, injuries and burns, peptic ulcer, pneumonia, kidney problems, asthma and TB. (Followed by: insecticide poisoning, sores, anaemia, psychiatric problems, kala azar, hypertension, gynecological problems, arthritis, bronchitis/emphysema.) The cost of running the inpatient department (general plus diabetes) for 12 months was BDT 3,800,000 (USD 52,000, NZD 69,000). This comes to BDT 2,500 (USD 34, NZD 46) per patient. With average stay 16 days that is BDT 160 (USD 2, NZD 3) per patient per day, which is extremely low cost.
Surgical Transfers: 33 patients (18% less than 2009) were transferred. The cost to the project was BDT 534,000 (USD 7,000, NZD 10,000) or BDT 16,000 (USD 200, NZD 300) per patient. This is a problem for the project. However there are many patients needing surgery which they cannot afford.
(12) The Diabetes Programme :
In a country of overwhelming poverty and rapidly increasing diabetes prevalence, KHCP has the only significant primary health care diabetes programme for the poor. It is essential for the masses of the people and the future of the country that its methods be studied, refined and copied.
Kailakuri Statistics for 2010 End of Year Patient Analysis Total number: 1,119 (7% more than 2009). Treatment: Insulin 59%, tablets (glibenclamide) 41%. Religio-ethnic breakdown: Muslim 97%, Hindu 2%, Christian 1%. Gender: male 47%, female 53%
Insulin Patients Total number treated in year: 711 (3% increase) Continuing from 2009 639 Started in 2010 +72
Defaulted –25 –54 Died –25 Continuing into 2011 657 (Four less-poor patients were transferred to BIRDEM district branches, too costly for the others).
End of Year Insulin Patient Analysis. Total no. of patients 657. Regular outpatient attendance 84%. Diabetes control (Benedict): good 67%, fair 27%. Distance of home from nearest sub-centre: within 15 miles 98% (0 – 5 miles 29%, 6 – 10 miles 23%). Functional literacy 64%. Under age 30y 51%, under 21y 11%. Economic status: very poor 53%, extremely poor 47% (based on home visit assessment). Male 50%, female 50%. Muslim 96%, Hindu 3%, Christian 1%.
Tablet (glibenclamide) patients Total number treated: 534 Continuing from 2009 409 Started 2010 +125
Defaulted/died - 23 Continuing into 2011 462 (49 less poor patient were transferred to BIRDEM district branches).
End of Year Tablet Patients: Total number of patients 462 Regular 74% Diabetes control (Benedict): good 64%, fair 22%. Distance of home from nearest sub-centre: within 15 miles 100% (0 – 5 miles 32%, 6 – 10 miles 35%). Functional literacy 78% Under 30y. age 9%, under 21y. 0% Economic situation: very poor 63%, extremely poor 33% (assessment by home visit). Male 42%, female 58%.
Diabetes Patients Admitted at Kailakuri Total 240 (5% less than 2009). Duration of admission 20 – 25 days. Male 42%, female 58% Reasons for admission: teaching 40%, non-diabetes problems 20%, diabetic ulcers 19%, other chronic complications of diabetes 9%, pregnancy/delivery 7%, severe uncontrolled diabetes 4%.
New Insulin Patients sent for concession-insulin registration to BIRDEM Hospital, Dhaka. Number of patients sent: 72. Travel cost BDT 167,000 (USD 2,000, NZD 3,000). Average cost per patient BDT 2,300 (USD 32, NZD 42). The high cost of sending patients to Dhaka is quickly recovered from the insulin price concessions.
Cost of Diabetic Stock
The cost to the project was BDT 4,343,000 (USD 59,000, NZD 79,000) about 34% of the KHCP expenditure for the year and about BDT 3,000 (USD 41, NZD 55) per patient. If the BIRDEM subsidy is added it becomes BDT 6,000 (USD 82, NZD 110) per patient per year. Diabetes patients are rehabilitated and able to live normal lives and the cost is extremely low. Serious acute diabetes complications are rare. Chronic complications are late and difficult to change without great cost increase and serious disruption of life-style. The causes of diabetes in Bangladesh still await clarification. This and the development of primary health care diabetes services for the poor are top national priorities.
(13) Staff, Training and Health Education :
The Kailakuri Health Care Project has 89 staff led by the medical officer-in-charge and the project manager.
I. The Health Action Team: 64 (72% of staff). i) Paramedics: 25 (28% of staff). ii) Health assistants: 11 (12% of staff). iii) Village mother-child care staff: 17 (19% of staff). iv) Cooks: 9 (10% of staff). v) Doctors: 2 (2% of staff). 37% of the team work with general patients 34% with diabetes, 26% in village mother child care and 3% with TB. They are supported by the two medically qualified doctors. A new long term doctor is urgently needed to replace the present medical officer-in-charge.
II. Support Staff: 25 (28% of staff). i) Project Manager: 1 (1% of staff). ii) Administration and office staff: 8 (9% of staff). iii) Finance staff: 3 (3% of staff). iv) Garden, compound, building maintenance, market, etc: 13 (15% of staff).
The project is labour-intensive. All but two of the staff are payed by the project, the lady doctor (by JOCS) and the project manager (by central office). Staff pay comprises 34% of all project costs. It is essential for the sustainability of the project to find an English speaking person for fund seeking, monitoring & correspondence, etc.
Six senior paramedics have undertaken the six month (LMAF) paramedic training course in Mymensingh. Senior paramedics give ongoing training to the rest of the staff. TB paramedics are trained and supervised by Damien Foundation. The five health educators give constant teaching in the outpatient and inpatient departments and in the diabetes sub-centres. Village staff give regular teaching in the villages. The very strong emphasis on teaching and awareness plus the fact that almost all staff are local ensures the transmission of important health concepts and messages throughout the community and brings about community change.
(14) Conclusion:
Change, Continuity and Sustainability
The KHCP is at a crucial stage. Bangladesh is changing very quickly. Kailakuri and its leadership must change. Local staff must take more and more control. The project must identify what is its essence, what it must hold in continuity and how to remain sustainable. The answers are obvious:
1) Actions: The aim is health for the poor done by the poor themselves. Five endeavors are involved in the achieving and sustaining of this: i) Ongoing daily activities of caring carried out by ordinary local people trained in the project. Health care must be scientifically appropriate, low cost, labour-intensive, based on simple clinical and public health logic with minimal investigations and drugs, done by highly motivated low level (but well trained) local staff and with strong emphasis on prevention and health education. It must be designed for, accessible to and effective for the poor. ii) Staff formation must be ongoing, within the project and appropriate to health and programme needs. iii) There must be constant evaluation and adjustment of methods and programmes. iv) Administration, funding security and programme structures must be built up. v) Critical personnel for sustainability must be instated: a) Ongoing fund-raising and donor communication requiring a fluent English speaking foreigner. Christine Steiner of New Zealand, who will join the project in May 2011 will fulfill this role, initially for a period of twelve months. This is the essential first step. b) Ongoing medical leadership and supervision requiring a new long term medical doctor. Dr. Edric Baker will then move to supporting these two people and gradually phasing out. 2. Ethos (prayer and solidarity). Bangladesh is a very religious country. The joint prayer of Muslims, Hindus and Christians and staff, patients and attendants is essential for grounding, mutual awareness and acceptance, unity, empathy, service ethic and motivation. Solidarity means the unity of the staff and their being one with and a part of the people which is essential for the development of a movement of the people. It requires staff to be from the poor community and not to disidentify, and it requires management committees representing the people, the staff and the central office.
3. Association:
“Work with, live with, pray with and make decisions together with” are the practical context of the aims, ethos and methods of health change. External consultants and skilled staff are needed but must make themselves part of the project, the poor community and the four “withs’’.
The poor must not remain deprived. Their health must improve without making them poorer in the process. They must know they can do it themselves, but they need support and they need to know that they are not on their own.
Thank you for your help.
Edric S. Baker Medical Officer in Charge. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||